Introduction: Shunt malfunction is a major challenge in the treatment of persistent hydrocephalus in both pediatric and adult populations. In the event of access failure, different access points have been described for CSF diversion including vetriculoperitoneal, ventriculoatrial, ventriculopleural, and ventriculo-gallbladder. We present a case in which the patient had multiple shunt failures and infections that exhausted all traditional shunting methods, which was definitively resolved with a ventriculoatrial shunt via the left innominate and hepatic veins.
Methods: A 10-year-old male with a 2q25 chromosomal deletion and multiple congenital pathologies including hydrocephalus presented with cranial asymmetry. Physical exam revealed grossly intact cranial nerves. The patient underwent a series of shunt revisions with various approaches including diversions to the peritoneum, right atrium, and gallbladder. VP shunt failure was detected when a pseudocyst was discovered following a presentation of lethargy. A VA shunt attempt failed due to abnormal neck vasculature. Subsequently, a ventriculopleural shunt resulted in pulmonary hypertension four months postoperatively. A second VA shunt was attempted after occluded iliac veins were visualized, with access to the right atrium being gained through the left innominate and hepatic veins. Follow-up at seven months revealed a normally functioning VA shunt and a baseline neurological exam.
Results: Hepatic venous access is a novel methodology for right atrial access in a VA shunt placement. Early and late shunt failures are extremely common obstacles in the treatment of chronic hydrocephalus. Well-known CSF diversion methods describe shunting to the peritoneum, right atrium, lung, and gallbladder. However, literature is lacking in nontraditional approaches for these diversions.
Conclusions: VA shunting is usually achieved via the internal jugular vein. Our patient presented with abnormal neck vasculature, and a novel access to the right atrium was attempted. Successful resolution of hydrocephalus was achieved, suggesting this as a valid flow diversion technique in the treatment armamentarium.
Patient Care: It is our hope that the method of CSF shunting presented in this case will be considered as a last resort when all other shunting attempts have failed for the hydrocephalus patient.
Learning Objectives: By the conclusion of this session, the participant should be able to: 1)Discuss alternate CSF diversion methods when ventriculoperitoneal shunting is not possible, 2)Understand the common challenges in pediatric shunting, 3)Contribute to the efforts of problem-solving during difficult access for CSF diversion in pediatric hydrocephalus.